Individual at Styal

Investigation into the circumstances surrounding the
death of a woman in December 2009,
at Christie’s Hospital,
whilst in the custody of HMP Styal
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2010
This is the report of an investigation into the circumstances surrounding the death of
a woman at Christie’s Hospital on 4 December 2010. She was a prisoner at HMP
Styal. A post mortem recorded the cause of her death as cancer. The investigation
was led by one of my colleagues.
I offer my sincere sympathy and condolences to the woman’s family and friends for
their loss. One of the Ombudsman’s family liaison officers contacted the woman’s
family during the investigation process. I apologise for the delay issuing my report
and any additional distress this may have caused.
I am grateful to the Governor and staff of Styal whose assistance was a great benefit
to my investigator.
I thank the local Primary Care Trust for appointing of a clinical reviewer and thank
him for his comprehensive report. As the woman died from natural causes, the
findings of the clinical review play a pivotal role in my report. Her family would have
preferred her to be nursed at home.
The review of the woman’s clinical care shows that she received compassionate
care and treatment equitable to what she would have received in the community.
Neither the clinical reviewer nor I make any recommendations. I recognise areas of
good practice, in particular the limited use of restraints, the woman’s release on
temporary licence and appointing a family liaison officer when she was diagnosed as
terminally ill.
This version of my report, published on my website, has been amended to remove
the names of the woman who died and those of staff and prisoners involved in my
investigation
Jane Webb
Acting Prisons and Probation Ombudsman August 2010
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CONTENTS
Summary 4
The Investigation Process 5
HMP Styal 6
Key Findings 8
Issues 13
Conclusion 15
3
SUMMARY
On arriving at HMP Styal, the woman who died told a nurse that she had been under
the care of a psychiatrist for ten years and had previously been in a psychiatric
hospital. She also said that she had seen her own doctor within the previous few
months about problems with her knees. She had a history of diabetes, blood
pressure and asthma, and was a smoker.
The woman was transferred to HMP Newhall on 5 June 2008. A nurse confirmed
her medical history and medication from Styal. She had regular contact with prison
doctors, nurses and members of the Mental Health In-reach Team (mental health
specialist practitioners). However, she was not happy at Newhall and, at her own
request, transferred back to Styal on 23 December.
On 6 January 2009, the woman complained of swelling in her neck and was referred
her to the Ear, Nose and Throat (ENT) specialist at the local hospital. She was seen
as an outpatient on 3 February and the consultant recorded that she had large lumps
on both sides of her neck and arranged further tests.
The woman was admitted to Wythenshawe Hospital on 9 February after complaining
of severe upper abdominal pain. She remained there for three weeks. She was re-
admitted to hospital on 8 March, and stayed until transferring to Christie’s Hospital
on 15 May. The cancer specialist registrar confirmed the diagnosis of cancer. In
conjunction with the hospital, prison healthcare staff put together a plan of care for
her which included cycles of outpatient chemotherapy.
Once discharged from hospital the woman continued to receive the daily care at
Styal as outlined by the hospital. A cancer nursing specialist visited the prison to
complete an assessment and offer support and guidance to healthcare staff.
Healthcare staff maintained contact with the hospital to update them on her condition
and clarify treatment and medication.
The woman was re-admitted to Christie’s Hospital on 2 November. She remained in
hospital and her condition deteriorated rapidly. The Deputy Governor authorised her
full release on temporary licence to Christie’s Hospital on 20 November, and began
the process of applying for compassionate release. The prison family liaison officer
kept the woman’s family informed of the actions the prison had taken.
The woman died in hospital on 4 December. The prison followed the guidance given
in Prison Service Order (PSO) 2710, “Follow up to death in custody” when breaking
the news of her death, maintaining contact with her family and offering assistance
towards the funeral expenses.
I am satisfied that the care and attention she received at Styal was equitable to what
she could have expected to receive in the community. I recognise the good practice
in family liaison, the effective and sensitive assessment of the use of restraints and
release on temporary licence.
4
THE INVESTIGATION PROCESS
1. My investigator obtained all the relevant records including the woman’s main
prison record and medical records. Notices were posted to staff and
prisoners about the investigation on 4 December 2009 but no contributions
were made.
2. The local Primary Care Trust asked a medical practitioner to review the
woman’s clinical care. I am grateful to him for undertaking this review. I
requested the review within ten weeks of her death and received it on 10
June 2010. The delay receiving the review has significantly affected the
timeliness of my own report.
3. My investigator contacted HM Coroner to inform him of the nature and scope
of my investigation and to request a copy of the post mortem report. Upon
completion, my report will be sent to the Coroner to assist his enquiries into
the woman’s death.
4. One of the Ombudsman’s family liaison officers contacted the woman’s family
at the beginning of the investigation and asked if they had any questions or
concerns about the care she received. The woman’s family believe that she
was disadvantaged in her medical treatment by being in prison because she
would have been able to be nursed at home if she had been living in the
community. Nevertheless, they told the family liaison officer that they were
impressed with the care and support they received from staff at Styal.
5. I have attempted to address the issue raised by the family within this report
and I hope that it provides a better understanding of how the woman was
looked after in the time leading up to her death.
5
HMP STYAL
6. HMP Styal opened as a women’s prison in 1962. In April 1999, the population
increased by 60 per cent following the opening of a new wing. Styal is the only
local prison for women prisoners serving the North West of England and North
Wales. It mainly holds women serving short sentences or those on remand.
The prison has an operational capacity of 460 women.
7. Styal is made up of two types of accommodation. There is a conventional
wing, Waite wing, where around 135 women live in single and shared cellular
accommodation. There are also 16 Victorian villas each accommodating up to
28 women in shared rooms of two to six. Each villa also has a common room
with televisions, stereos, DVD players, and a variety of board games. These
houses have lower levels of staffing, with no staff on duty during the night.
Location on Waite wing or the houses is determined by the level of risk that a
woman presents. The woman who died lived in a single cell.
8. Healthcare services at Styal are commissioned by the local Primary Care
Trust. A doctor is based in healthcare during the daytime and evenings on
weekdays. An on call service is available overnight and at weekends. There
are nurses in the prison throughout the day and night. Nursing staff are based
in the first night centre during the night, as there are no inpatient facilities at
the prison.
9. HM Chief Inspector of Prisons conducted a full announced inspection of the
prison in September 2008. The Chief Inspector reported that:
“Women had reasonable access to most health services, but there was
significant pressure on services and staff struggled to meet women’s
considerable mental and physical health needs.”
10. The Chief Inspector went on to say that some clinical services were
“underdeveloped” and that “access to some health services was not as good
as in the community”. She noted that there were no chronic disease (a
disease that is long lasting or recurrent, including asthma) clinics and her
recommendations to the Prison Service included the following:
“Chronic disease management should be improved and women should be
seen regularly with support from community nurse specialists.”
11. Prisons are also monitored by an Independent Monitoring Board (IMB), whose
members are drawn from the local community. They have full access to each
prisoner and every part of the establishment. The last available annual report
by the Styal IMB covers the period 2008 to 2009. The report made the
following comments regarding healthcare:
“This has been a difficult year due to the protracted commissioning and
tendering process for all Healthcare services.
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“There are several areas of Healthcare where the building provision is
inadequate and does not comply with Standards for Health Privacy and
Dignity.
“The Board is pleased to note that the use of Agency nurses is likely to be
greatly reduced in the future under the new Health Care Contract, as at
times this arrangement has fallen far short of prison standards.
“The waste of resources due to prisoners not attending appointments
continues to be of major concern. This is a prison management issue as
well and needs to be tackled jointly with Healthcare Management.
“Staff at Styal is a highly motivated team of professionals. The Board
acknowledges the high level of care they provide to the prisoners in their
care.”
12. The woman’s death was the eighth to have occurred at Styal since April
2004, when the Ombudsman began investigating deaths in prison custody in
England and Wales. Her death was the third due to natural causes. There
are no similarities between the issues addressed in the previous
investigations.
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KEY FINDINGS
13. The woman who died lived with her teenage daughter. She had a history of
mental illness, diabetes, asthma and blood pressure. She smoked and had a
history of illicit drug use.
14. The woman was convicted of wounding with intent and sentenced to three
years and ten months imprisonment on 12 May 2008. She was sent to HMP
Styal where a nurse conducted an initial healthscreen check. The woman
told the nurse that she had been under the care of a psychiatrist for ten years
and named her current psychiatrist. She had previously been in a psychiatric
hospital. She also told the nurse that she had seen her general practitioner
within the previous few months regarding problems with her knees. She
confirmed her medical history to the reception nurse.
15. The nurse recorded that the woman’s prescribed medication was tramadol (for
anxiety), citalopram (anti-depressant medication), irbesartan (for blood
pressure), bendroflumethiazide (also for blood pressure), amlodipine (another
blood pressure medication), simvastatin (to reduce cholesterol), levothyroxine
(for an underactive thyroid), Seretide inhaler (for asthma), salbutamol inhaler
(also for asthma) and metformin (for diabetes).
16. The nurse also recorded that her weight was 120kg and her blood pressure
was 135/94 with a pulse of 90. (The normal range for blood pressure is
100/70 to 140/90, although the pressure varies throughout the day depending
on the individual’s activities. A blood pressure reading of greater than 140/90
is classed as high and a reading of 90/60 or below is classed as low.)
17. Later that same day a prison doctor saw the woman and confirmed her
medical history. In response to routine questions, the doctor noted that she
was allergic to penicillin, did not depend on alcohol and was not thinking about
harming herself. She told the doctor that she had not taken illicit drugs for two
years.
18. A nurse attempted to contact the woman’s current psychiatrist by telephone on
16 May, but was advised that no one was available and to call back the
following Monday. The nurse spoke to his secretary on 19 May to obtain the
necessary information to assist healthcare staff at Styal to plan the care that
the woman required.
19. A member of the Mental Health In-Reach Team (MHIT) assessed the woman
on 28 May. She recorded that the woman’s mood was a little low and she
appeared anxious. She was worried about her daughter who was due to start
at university. She said that she had built up a good rapport with her
psychiatrist over a number of years. She said that she had fleeting thoughts of
harming herself but had no intention of acting on them.
20. The woman transferred to HMP Newhall on 5 June. On arrival she was seen
by a nurse who confirmed her medical history and the medication prescribed
at Styal. The nurse assessed her as fit to live on a normal prison wing and go
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to work. She could be in a single or shared cell (a cell sharing risk
assessment is completed which considers the level of risk to the prisoner
themselves or to others). The next day a prison doctor confirmed and
authorised the prescribed medication that she had taken at Styal.
21. The woman was not happy at Newhall and asked to transfer back to Styal.
This request was agreed, but she had to remain at Newhall until 23 December
due to prisoner numbers. During her time at Newhall the woman had regular
contact with the prison doctors, nurses and members of the MHIT.
22. On 23 December, she transferred back to Styal. A nurse conducted the
healthscreen check to confirm her medical history and current medication,
which she brought with her from Newhall. The nurse recorded that her blood
pressure was 103/74 with a pulse of 83, and her weight was 107kg. A prison
doctor saw her later that afternoon and authorised that the medication should
continue.
23. Two weeks later, on 6 January 2009 the prison doctor who saw the woman on
her return to Styal saw the woman as she complained of swelling in her neck.
The doctor recorded that there was no light headedness nor voice disturbance.
He referred her to the Ear, Nose and Throat (ENT) specialist at the local
hospital.
24. On 22 January, the woman saw another prison doctor as she had complained
of not hearing well and experienced pain in her knees. The doctor recorded
that the woman was unable to hear fingers being rubbed together, and that
she had a history of osteoarthritis. The doctor referred her to the local hospital
to see both the orthopaedic and ENT specialists. Healthcare staff contacted a
local hospital to establish when she would have an appointment following the
doctor who saw her on arrival back to Styal’s referral. The hospital confirmed
that this would be in February.
25. The woman saw another prison doctor on 2 February as she experienced post
menopausal bleeding and upper abdominal pain. The doctor recorded that
she no longer had hot flushes and usually had no pain. The doctor made a
gynaecological referral to the local hospital.
26. The next day the woman was taken to the local hospital for her outpatient
appointment with a Clinical Fellow in ENT surgery. He recorded that she had
large lumps on both sides of her neck. On examination he found that the
lumps were not particularly tender but moved when she swallowed. He
arranged for her to have an ultrasound scan of her neck and a magnetic
resonance imaging scan (MRI) (a technique that gives a detailed picture of the
inside of the body, used to diagnose conditions that affect organs, tissue and
bone).
27. Two days later the woman saw the prison doctor who saw her regarding her
hearing and knee pain as she complained of continued upper abdominal pain.
She told the doctor that she experienced pain and stomach cramps on eating,
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as well as a burning sensation afterwards. The doctor prescribed mebeverine
hydrochloride (for abdominal cramps).
28. On 9 February, the woman saw the prison doctor the she had seen on 2
February as she still had abdominal pain and had vomited on several
occasions. The doctor recorded that she had a high temperature and, given
her recent history, arranged for her to be admitted immediately to hospital.
29. The woman was admitted to the local hospital that day. A bedwatch risk
assessment was completed to assess the level of restraint, the number of
escorting officers and other security issues. She was accompanied by two
officers, using a long escort chain (a two metre chain with a single cuff at
either end) which would be removed when she was being treated. She
remained in hospital for three weeks. She had numerous tests and her family
visited. The escort officers maintained daily contact with the prison to provide
an update on her condition.
30. On 27 February a hospital consultant saw the woman to explain the test
results and further treatment. At the woman’s request, her sister was present.
The consultant told the woman that the results of the tests could take seven to
ten days, and she would be re-admitted to hospital once they had been
received. The consultant was happy for her to return to Styal until coming
back to hospital. She returned to the prison later that day.
31. The woman was taken back into hospital on 8 March. Again a bedwatch risk
assessment was completed which authorised the same level of security.
Escort officers kept the prison informed daily of her condition and also
healthcare staff maintained contact with the hospital.
32. The hospital consultant wrote to the Governor at Styal on 25 March. He wrote
that, in his opinion, the woman had cancer of the pancreas and it was highly
probable that she would require continued hospital care. The consultant
asked the Governor to consider easing the visiting and telephone restrictions
that were in place. Following receipt of this letter a further risk assessment
was completed and all the restraints were removed, although the escort
officers remained. Visits were allowed subject to security searches.
33. The woman continued to be treated in hospital. A further risk assessment was
completed on 24 April which reduced the level of escort to one officer. Three
days later she was released on temporary licence (ROTL). The ROTL allowed
her to be temporarily released from custody to the care of the hospital, and no
escort or restraints were required. On 15 May, she transferred to another
hospital.
34. Three days later on 18 May a specialist registrar saw the woman. He told her
that a diagnosis of diffuse large B-cell lymphoma (cancer originating in the
lymph nodes) had been confirmed. Her plan of care included eight cycles of
outpatient chemotherapy treatment. On discharge from hospital she was
prescribed the following medication:
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(cid:127) amitryptiline (an antidepressant)
(cid:127) omeprazole (for gastric conditions)
(cid:127) lignocaine (strong pain relief)
(cid:127) zopiclone (for insomnia)
(cid:127) levothyroxine
(cid:127) allopurinol (for excess uric acid in the blood)
(cid:127) metformin
(cid:127) citalopram
(cid:127) oxycontin (for severe pain relief)
(cid:127) docusate sodium (for constipation).
35. A nurse from healthcare at Styal visited the woman in hospital on 22 May. The
nurse carried out a full assessment to ensure that her needs would be met and
a care plan was put in place on her discharge from hospital. The care plan
included providing her with a carer from the Primary Care Trust.
36. The woman was discharged from hospital back to Styal on 2 June. At her
request she returned to her cell so she could be close to friends and
healthcare staff monitored her regularly throughout the day. She continued to
receive the daily care as outlined by the hospital. In addition a MacMillan
cancer nursing specialist visited the prison a week later on 9 June to complete
an assessment and offer support and guidance to healthcare staff. Healthcare
staff maintained contact with the hospital to update them on her condition and
clarify treatment and medication.
37. Between 2 June and 22 October, the woman attended hospital for her
scheduled outpatient chemotherapy treatment. On each occasion the prison
risk assessment authorised that the woman could be accompanied by one
escort officer and no restraints were required.
38. On 22 October, she complained of severe abdominal pain that she had not
experienced before. Another prison doctor saw the woman and recorded that
she was doubled over in pain, looked unwell and was vomiting small amounts
of fluid. The doctor prescribed a double dose of pain relief and said that he
would review her within one hour. The doctor conducted the review 40
minutes later and, as there was no improvement, called for an emergency
ambulance. The paramedics arrived and, as they were not allowed to take
patients directly to the hospital she had previously been at, instead took her to
another local hospital.
39. A new risk assessment was completed and, due to her condition, a single
officer escorted her with no restraints used. She remained in hospital for
seven days. During this time prison healthcare staff maintained contact with
the hospital for updates on her condition. The hospital staff confirmed that she
had a further scan. She was given additional pain relief following advice from
the other hospital, who had seen her within a few days of admission. She was
also seen by a physiotherapist who assessed that no further treatment was
required as she was able to walk, wash and dress herself.
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40. The woman returned to Styal on 29 October and her care continued. Four
days later she attended the local hospital for the arranged outpatient
appointment. Following examination and confirmation of the scan undertaken
at the hospital she had recently been admitted to, the decision was taken to
admit her to hospital as she was expected to deteriorate. A risk assessment
was completed and the single officer remained in place with no restraints in
place.
41. The prison doctor, who saw her regarding her hearing and knee pain,
contacted the local hospital on 10 November to obtain an update on her
condition. A hospital doctor told him that she had deteriorated. The cancer
had spread to her liver and possibly the brain, and confirmed that it was
unlikely that she would return to the prison.
42. Styal received a letter from the local hospital on 13 November, which
confirmed that her prognosis was very poor and her life expectancy limited to a
few months.
43. On 20 November, the Deputy Governor authorised the woman full ROTL,
which meant that she was placed into the care of the local hospital with no
further supervision from the Prison Service. A governor was appointed as the
prison’s family liaison officer. He informed the woman that the prison had
started the process for early compassionate release from custody. The
governor liaised with her family to ensure that they were aware of the actions
being taken.
44. Senior managers at Styal had collated and completed the required
documentation for her compassionate release application and forwarded it to
the Ministry of Justice for consideration on 25 November.
45. The doctor who saw the woman regarding her hearing and knee pain
contacted the local hospital on 27 November to obtain an update on her
condition. The doctor was told that her condition had deteriorated rapidly and
no further chemotherapy would be offered. She was too poorly to transfer to a
hospice and the likely outcome was that she would die within two weeks.
46. Four days later the doctor again contacted the local hospital and spoke with
the hospital doctor he had spoken to on 10 November. The hospital doctor
said that the woman had been placed on the care for the dying pathway (a
plan of care for people in the final stages of a terminal illness), and would
remain under the care of staff at the hospital until she passed away.
47. On 4 December, the local hospital contacted Styal to inform them that the
woman had died at 1.30am. The prison family liaison officer maintained
contact with the family and offered assistance towards the cost of the funeral
expenses.
12
ISSUES
Clinical care
48. Both the clinical reviewer and I are satisfied that the care the woman received
was equitable to what she could have expected in the community. The clinical
review makes the following comments regarding her clinical care:
“It is unarguable that the woman received a level and standard of care at
HMP Styal which would be considered to be equivalent to the standard of
care which she would have received had she consulted a relevant
healthcare professional in the community.
“From the evidence available to me at admission to HMP Styal she did not
have any symptoms or signs, the investigation of which could have led to
an earlier diagnosis.
“The record shows that care was delivered to the woman in a well planned
and co-ordinated manner.
“My view is that plans to meet her healthcare needs were sufficiently
comprehensive and robust.
“It is also clear that there was good communication between the
healthcare team at HMP Styal and the local hospital.
“I am able to say that the woman received care and treatment of a good
standard at HMP Styal. She was referred to hospital in a timely manner
on a number of occasions and her symptoms following the diagnosis of
her tumour were managed in a competent and compassionate manner.
She also was supported by Macmillan nurses. All her visits to the local
hospital were facilitated.”
I am pleased that the prison made all the arrangements necessary for the
woman to receive the specialist care that she required.
Use of restraints and release on temporary licence
49. Unfortunately there have been too many reports in which the Ombudsman has
criticised the use of restraints when prisoners are in hospital outside of the
prison. It is pleasing therefore to recognise the good practice adopted by
Styal. I believe that staff effectively and sensitively assessed the use of
restraints and put minimum levels in place. The woman’s release on
temporary licence ensured that she was treated with dignity and respect during
her last days.
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Family liaison
50. I also recognise the work of the governor who was appointed as the prison’s
family liaison officer when the woman was diagnosed as terminally ill. By
appointing a family liaison officer to keep in touch with her family at the end of
her life, I believe that the prison exceeded the guidance given in PSO 2710,
“Follow up to death in custody”. It is good practice for family liaison officers to
be appointed for the families of all terminally ill prisoners and I commend Styal
for their initiative. The woman’s family told my family liaison officer that they
were very impressed with the support given by the prison.
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CONCLUSION
51. During her time at Styal, the woman had regular contact with healthcare staff
and doctors which was well documented. I believe that the care she received
was of a good standard and was well co-ordinated with the hospital. I judge
that it was equitable to what she could have expected in the community. The
clinical review confirms that her medical treatment was appropriate and that
her death could not have been prevented.
52. I recognise the good practice adopted by Styal in the effective and sensitive
assessment of the use of restraints and the use of temporary release on
licence.
At the consultation stage of the report the woman’s family wished it noted
within the report that both them and the woman who died found the use of
restraints on her upsetting for them and feel the report does not reflect how
difficult this had been for them all. The family also wish it noted that it is their
opinion that the prison did not have the facilities to treat her and although
some members of staff tried their best her treatment and pain relief could not
be managed within the prison setting.
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